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This is a guest post by David Wiss MS RDN. David is the founder of Nutrition In Recovery (www.NutritionInRecovery.com), which specializes in: Addictions, Eating Disorders, Mental Health, Body Image, and General Wellness.
Addiction rates in the United States have skyrocketed in recent years. Recent estimates suggest that 8% of people aged 12 or required substance use treatment in the past year (1). Since the turn of the century we have experienced a heartbreaking opiate epidemic, leading to significant growth in the drug treatment industry (1). In Los Angeles, there are hundreds of licensed treatment facilities (2) and there are over 2,000 sober living facilities, many of which are unregistered. People come from all over the country for treatment and extended care in Southern California because of its perceived expertise in addiction treatment.
Many experts believe that prescription drug misuse has played a significant role in the rising rates of heroin addiction, as many individuals progress through a predictable trajectory of hydrocodone to oxycodone to heroin (3). Despite countless arrests, heroin appears to continue flowing in from Mexico to all parts of the country, particularly middle class suburbs in the Midwest (3). In response to the drug epidemic, pain clinics known as “pill mills” have been shut down across the country. Lawsuits against makers of Oxycontin have forced pharmaceutical companies to reformulate their opiate medications.
From a public health perspective, the addiction problem appears to be relentless with substances of abuse increasing in potency. Meanwhile highly accessible and highly palatable food is a significant contributor to the changing human brain and addiction epidemic. There is increasing evidence to suggest that contemporary food (high in fat and sugar, low in fiber) is stimulating an evolution of the human microbiome, leading to a "Western gut." (4) Some researchers believe that the conflict created by resource competition between humans and microbes creates an ongoing evolutionary arms race, and is a driver of metabolic disease (5). There is also evidence of the microbiome influencing anxiety and depression (6) via the gut-brain axis, potentially due to mediators that travel to the amygdala (7).
The concept of food addiction is no longer controversial. There is sufficient data in animals and humans to support this statement. What remains controversial is the nutritional approach to treatment. Based on what we know about addiction, it makes sense to work towards reducing exposure to addictive substances. Meanwhile, many of us who specialize in nutrition counseling for eating disorders can attest to the fact that attempts to restrict certain foods can lead to bingeing and the subsequent guilt, shame, and remorse. Individuals seeking addiction treatment should routinely be screened for an eating disorder and treated appropriately.
Let us assume a teenager consumes a diet largely comprised of highly processed convenience food (typically designed for maximum profit margins). These include snack foods such as chips and fruit snacks, frozen foods such as burritos and ice cream, delivery food such as pizza and Chinese, and fast food restaurant fare. The teenager has limited or no experience buying groceries and preparing food. Without even realizing it, most food choices are made based on taste, convenience, and familiarity. The gut will not be primed for digestion of fibrous fruits and vegetables, and there exists a strong preference for food that is salty (chips) or sweet and easily digestible (sweetened cereal with milk). Although there are no apparent weight problems, this can represent a form of food addiction, because the teen rejects foods that do not stimulate the reward system. This relationship to food is increasingly common in our society, and represents a systemic issue rather than an individual problem.
Fast forward: our teenager is now 23 years old, strung out on heroin, xanax, crystal meth, and alcohol. The patient presents to an addiction treatment center in Southern California 15 pounds underweight. The primary source of dopamine stimulation (drugs) is gone and the anhedonia sets in. Post detoxification we can predict an increase in substance-seeking behavior, predictable caffeine, nicotine, and sugar. The patient has progressed to coffee with creamer and sugar several times per day in addition to energy drinks. The patient is likely to smoke a half a pack of cigarettes before eating any food each day. Highly palatable food may feel like the sole source of pleasure that is left, yet there is no interest in cooking, particularly since there is a chef to prepare delicious meals such as tacos, spaghetti and meatballs, and teriyaki chicken.
The patient claims to be interested in recovering from addiction, getting out of their withdrawal-related depression, and eventually reducing some of their medications. In their first month of treatment they often regain their lost weight and develop patterns of night eating and a new habit of sour candy throughout the afternoon. Old wisdom from the recovery community would suggest that a liberalized approach to sweets, nicotine, and caffeine is favorable to help the individual get past the immediate crisis. New wisdom suggests that this behavior is a form of cross addiction that should be addressed early in recovery.
Once the individual has gotten through the acute detox, it is time for a nutrition intervention. This is required to get this population to make changes that they are not likely to make on their own. This intervention requires a Registered Dietitian Nutritionist to provide group education, individual counseling, and working with the culinary staff to implement guidelines for the facility. The guidelines that can be implemented look something like:
Requirement for breakfast
Minimum 2 liters water/day
Fruit or vegetable with every meal (raw vegetable at least once/day)
Bean, nut, or seed with every meal/snack
Nutrition group once/week
Cooking class twice/week
Dessert served only twice/week (fresh fruit served on other nights)
No sodas, energy drinks, or other sweetened beverages
No artificial sweeteners (or other "diet foods")
No refined grains (whole grains only)
No fried foods (including frozen foods previously fried)
No foods that cannot be classified into the Food Group System
This type of intervention is designed to reduce the potential for addictive eating in early recovery. Shifting the patient towards a diet that is high in fiber and low in sugar can make a difference in recovery outcomes, although it is yet to be adequately described in the scientific literature. Additionally, preventing individuals from gaining more than 10 lbs. per month can decrease the likelihood that body image disturbances will eventually lead to relapse. This is a major problem that has received scant attention.
Nutrition can be used to improve the gut microbiota and to eventually help rewire the brain. In one study, alcoholics with gut leakiness had higher scores of depression, anxiety, and alcohol craving (8). Given the addiction epidemic and its associated healthcare burden, it is time to prioritize nutrition as a treatment modality. While there may be some resistance from the patients (as well as the staff), nutrition interventions will be an important part of the recovery process. Advances in our understanding of food addiction should point to the necessity of addressing eating behavior in drug addiction. Meanwhile, nutrition should never be punitive and should be framed as a helpful component of recovery. The focus should always be on what to eat (as opposed to what not to eat) as a way of crowding out the less desirable foods.
"Food for thought is no substitute for the real thing." - Walt Kelly
References
1. Lipari, R. N., Park-Lee, E., & Van Horn, S. (2016, September). America's need for and receipt of substance use treatment in 2015. The CBHSQ Report. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from: http://www.samhsa.gov/data/sites/default/files/report_2716/ShortReport-…
2. https://findtreatment.samhsa.gov/
3. Quinones, S. (2016). Dreamland: The true tale of America's opiate epidemic. New York: Bloomsbury Press.
4. Payne, A. N., Chassard, C., & Lacroix, C. (2012). Gut microbial adaptation to dietary consumption of fructose, artificial sweeteners and sugar alcohols: Implications for host-microbe interactions contributing to obesity. Obesity Reviews, 13, 799-809.
5. Wasielewski, H., Alcock, J., & Aktipis, A. (2016). Resource conflict and cooperation between human host and gut microbiota: Implications for nutrition and health. Annals of the New York Academy of Sciences. doi:10.1111/nyas.13118
6. Foster, J. A., & Neufeld, K. M. (2013). Gut-brain axis: How the microbiome influences anxiety and depression. Trends in Neurosciences, 36(5), 305-312.
7. Gorky, J., & Schwaber, J. (2016). The role of the gut-brain axis in alcohol use disorders. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 65, 234-241.
8. Leclercq, S., Matamoros, S., Cani, P. D., Neyrinck, A. M., Jamar, F., Starkel, P., ...Delzenne, N. M. (2014). Intestinal permeability, gut-bacterial dysbiosis, and behavioral markers of alcohol-dependence severity. Proceedings of the National Academy of the Sciences. Retrieved from www.pnas.org/cgi/doi/10.1073/pnas.1415174111
Dr. Nicole Avena is a research neuroscientist/psychologist and expert in the fields of nutrition, diet and addiction. She has published over 70 scholarly journal articles, as well as several book chapters on topics related to food, addiction, obesity and eating disorders. Her research achievements have been honored by awards from several groups including the New York Academy of Sciences, the American Psychological Association, the National Institute on Drug Abuse, and her research has been funded by the National Institutes of Health (NIH) and National Eating Disorders Association. She edited the book, Animal Models of Eating Disorders (Springer/Humana Press, 2013), and she has two authored books: Why Diets Fail (Ten Speed/Crown) and What to Eat When You're Pregnant (Ten Speed/Crown)
Learn more on her website.
